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How toManage Diverticular Abscess Not
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Amenable toPercutaneous Drainage?
BhuwanGiri andGustavoA.Rubio
Introduction
Patients with acute left sided colonic diverticulitis complicated by abscess can be
managed either medically or surgically depending on presentation and severity of
disease. Abscesses 3cm or greater in patients without generalized peritonitis are
managed with percutaneous drainage, if feasible, in conjunction with antibiotics [1,
2]. In patients who fail medical management, or those that are not amenable to per-
cutaneous drainage, management options include colonic primary resection and
anastomosis (PRA) with or without a diverting loop ileostomy (DLI) or a Hartmann
procedure [1]. Additionally, laparoscopic peritoneal lavage (LPL) with or without
fecal diversion followed by staged colon resection has also been reported [3, 4]. In
patients with Hinchey II diverticulitis treated medically, treatment failure and
abscess recurrence rate is as high as 25% with long term follow up showing lower
recurrence rate with percutaneous drainage compared to antibiotics alone [2, 5].
This is mostly because smaller abscesses are treated medically whereas larger
abscesses tend to be treated with percutaneous drainage. Therefore, percutaneous
drainage is the intervention of choice for simple abscesses with a success rate of
more than 80%. Complex abscesses (loculations, stulas, infected uid collections
with drainage route through viscera) have higher failure rates [6]. Optimal treatment
35
B. Giri (*)
DeWitt Daughtry Family Department of Surgery, University of Miami Leondard M.Miller
School of Medicine, Miami, FL, USA
Jackson Health System, Miami, FL, USA
e-mail: bhuwan.giri@med.miami.edu
G. A. Rubio
Jackson Health System, Miami, FL, USA
e-mail: grubio87@med.miami.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_35
387
388
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B. Giri and G. A. Rubio
strategy for diverticular abscesses not amenable to percutaneous drainage remains
debated. In this chapter, we evaluate the various strategies used to treat diverticular
abscesses not amenable to percutaneous drainage in Hinchey Ib/II acute
diverticulitis.
Patients
Patients with
diverticular abscess
not amenable to
percutaneous drainage
Intervention Comparator
Antibiotics alone,
laparoscopic peritoneal
lavage, or fecal diversion
followed by colon
resection
Colon
resection
Outcomes
Complications,
recurrence, functional
outcomes, need for
permanent ostomy
Search Strategy
A Pubmed, EMBASE and Cochrane database search using the terms “Diverticulitis”,
“Diverticular abscess”+“colectomy” “Hinchey I/1”, “Hinchey 2/II” and “ostomy”
was performed. Relevant articles were selected for review. Articles whose main text
was not in English, and articles published more than 20years ago were excluded
from review.
Studies were excluded if they did not specify if patients with Hinchey <2 were
included. Studies that included surgical treatment after failure of medical or percutaneous management were included. Only the most recent study was included if
similar studies from the same institution were encountered. References of the
included studies and the related articles were reviewed to identify additional studies
that were incorporated as appropriate.
Results
Few studies have directly evaluated the best treatment strategy for patients with
acute left sided colonic diverticulitis complicated by abscess not amenable to percutaneous drainage. Only observational studies have been published on this specic
topic. Majority of studies did not specically compare different interventions (e.g.
laparoscopic lavage vs sigmoid resection). Of the studies listed below, majority only
had a subset of patients with Hinchey Ib/II diverticular abscesses. Medical management with antibiotics alone was typically the initial intervention in stable patients
with inaccessible or small (<3cm) diverticular abscesses. Across studies, failure of
nonoperative management with antibiotics alone was 20–25% [2, 7, 8]. In one
study, all patients with abscesses 5cm or greater required either percutaneous drainage or surgery [7]. Of stable patients treated with surgery, indications usually
included failure of non-operative management (either antibiotics alone or percutaneous drainage). Studies also included patients with abscesses treated with surgery
due to generalized purulent peritonitis (Hinchey III). Operations included laparoscopic/open sigmoid resection with primary anastomosis +/− diverting ostomy,
35 How toManage Diverticular Abscess Not Amenable toPercutaneous Drainage?
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389
laparoscopic/open Hartmann procedure, or laparoscopic lavage +/− diverting
ostomy. Tartaglia etal. [4] compared laparoscopic lavage (LPL) versus laparoscopic
sigmoid (LS) colectomy in patients with diverticular abscesses failing medical management. Study population included 29% of patients with Hinchey II presentation.
In the LPL group, 18% required reoperation and there was increased rate of long
term recurrence compared with LS group. LS group included 37% Hartmann procedure, 50% primary anastomosis without DLI, and 13% primary anastomosis with
DLI.LS group had an 18% morbidity rate and 74% rate of ostomy reversal [4].
Therefore, authors concluded that laparoscopic lavage carried higher risk of treatment failure, recurrence, and morbidity compared to laparoscopic sigmoid resection. Rosen etal. [7] also reported lower recurrence rate 7% (vs 21%) in patients
who underwent sigmoid resection during index hospitalization. Finally, a single
institution study evaluated management with initial laparoscopic diverting loop
ileostomy followed by staged sigmoid resection and subsequent ileostomy closure
in patients failing medical management or at high operative risk [3]. 6/19 patients
included in the study had evidence of diverticular abscess. There were no initial
treatment failures and majority (84%) of patients had ostomies reversed (Table35.1).
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Quality of evidence
Level IV
Relative risk
for therapy B
LS: No recurrence for
LS group p=0.003.
74% (14/19) had their
Typical risk
for therapy A
LPL: 6/22 patients who
had complete recovery
from the procedure
ostomies reversed and
remaining 4 had end
colostomy (HA).
No signicant
differences were found
in overall morbidity,
mean length of
postoperative stay, or
presented one or more
episodes of recurrent
diverticulitis.
18.5% rate of
reoperation
Level IV
stoma closure rate.
Incisional hernia rate
was signicantly higher
in the HA group (12.5%
vs 42.8%; p=0.034)
Antibiotics alone
CT drainage
B. Giri and G. A. Rubio
19% failed antibiotics
alone. (p=0.26)
16% underwent
emergency surgery
(P=0.24)
33% failure in CT
guidance group
29% underwent
emergency surgery
12 patients (35%)
16 patients (50%)
subsequently underwent
an elective sigmoid
resection (P=0.31).
0 post op deaths in
antibiotics alone group
Median size of abscess
was 4 (3–10) cm
subsequently underwent
an elective sigmoid
resection
Four postoperative
deaths (26.6%)
Median size of abscess
was 6 (3–18) cm
(P=0.002)
Laparoscopic peritoneal
lavage (LPL) vs
laparoscopic
sigmoidectomy (LS) in
patients with modied
Patients Outcome classication
66 patients were
enrolled with pelvic
abscess not amenable to
conservative
management and
Study
Tartaglia, 2019 [4]
Prospective multi center
study
Table 35.1 Summary of results
n=66
Hinchey II, not
responding to medical
therapy
Hinchey 3 acute
diverticulitis
29% of patients had
Hinchey II disease (46%
underwent laparoscopic
lavage and 42%
underwent laparoscopic
Primary outcome of
sigmoidectomy)
34 patients underwent
Brandt, 2006 [8]
failure of conservative
management
(emergency surgery,
signs of worsening
sepsis, or abscess
recurrence with 4weeks
of drainage
abscess drainage under
CT scan guidance and
32 patients were treated
with antibiotic therapy
(mostly because CT
scan guided abscess
drainage was considered
not technically feasible
Case control study in
patients with Hinchey II
diverticulitis. Single
institution study
comparing patients who
underwent abscess
drainage under CT
guidance vs treated with
by interventional
radiology team)
antibiotics alone.
35 How toManage Diverticular Abscess Not Amenable toPercutaneous Drainage?
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(continued)
Level V
Quality of evidence
Open resection
Wound infection: 6/16
Relative risk
for therapy B
Typical risk
for therapy A
(37.5%), p<0.05
Laparoscopic resection
Wound infection: 4/36
(11%)
Overall complications
9/16 43.8% P<−.05
Overall complications:
6/136 16.7%
Major complications
(leakage, obstructions,
bleeding and mortality
and recurrence similar
between two groups)
Level V
28/113 (25%) not
amenable to
percutaneous drainage
required surgery during
index hospitalization
3% done
113/134 (84%) not
amenable to
percutaneous drainage
85/113 (75%) managed
non- operatively during
index hospitalization
laparoscopically
50% had diverting
stoma
7% recurrence rate
21% recurrence rate
All abscesses >5cm
required IR drainage or
surgery
391
Overall complication
rate, wound infection,
hospital stay compared
between two groups.
58 patients total
36 patients underwent
laparoscopic resection
and 16 patients
underwent open colon
Patients Outcome classication
Katsuno 2011 [11]
Single institution
Study
resection
Japanese retrospective
review of laparoscopic
one stage resection vs
open sigmoid resection
in Hinchey I and II
acute diverticulitis.
Laparoscopic surgery
was performed for all
patients with recurrent
episodes. No
preoperative
percutaneous drainage
Primary outcome was
failure of conservative
management (need for
surgery), LOS,
134 patients with
Hinchey Ib/II
diverticulitis. 78%
treated non-operatively
Rosen, 2019 [7]
Single institution
of abscess
retrospective study
recurrence rates, rate of
stoma formation
(including 62% with
antibiotics alone). 22%
underwent sigmoid
resection +/− ostomy
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Relative risk
Quality of evidence
Level III
for therapy B
Acute surgery
associated with 12.1%
mortality rate
B. Giri and G. A. Rubio
Level V
20% failure of
Typical risk
for therapy A
Treatment failure, short
N=8766 patients
Patients Outcome classication
Gregensen, 2016 [2]
Study
Table 35.1 (continued)
non- operative
management
Abscesses <3cm
typically treated
adequately with
antibiotics alone
25% recurrence
term mortality,
recurrence.
Management options
included antibiotics
alone, percutaneous
drainage, or surgery
Systematic review, 42
studies (all
observational) including
Hinchey I/II patients
with abscess
6 of 19 patients had
16% recurrence after
percutaneous drainage
abscess pre- operatively
No patient needed
resection during index
admission
Need for sigmoid
resection for failure to
improve
19 patients with acute
diverticulitis underwent
DLI without initial
resection
Graham, 2022 [3]
Single institution
retrospective study
(published abstract)
84% underwent ostomy
reversal
35 How toManage Diverticular Abscess Not Amenable toPercutaneous Drainage?
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393
Recommendations Based ontheData
For stable patients with Hinchey Ib/II diverticulitis and small (<3cm) abscesses,
initial nonoperative management with antibiotics alone is treatment of choice
(Quality of evidence: moderate; Strong recommendation)
For stable patients with diverticular abscesses >3cm not amenable to percutaneous
drainage, initial nonoperative management with antibiotics alone can be consid-
ered (Quality of evidence: Low; Strong recommendation)
Patients with diverticular abscesses that fail non-operative management with antibi-
otics alone should undergo sigmoid colectomy (primary anastomosis +/− divert-
ing loop ileostomy or Hartmann procedure) (Quality of evidence: Low; Strong
recommendation)
Minimally-invasive approach to sigmoid resection is preferred (Quality of evidence:
Moderate; Strong recommendation)
Laparoscopic lavage is associated with higher treatment failure and recurrence rates
for patients with diverticular abscess and is generally not recommended (Quality
of evidence: Low; Weak recommendation)
In high operative risk patients, a staged approach with initial laparoscopic diverting
loop ileostomy with interval sigmoid resection and ileostomy closure can be
considered (Quality of evidence: Low, Weak recommendation).
A Personal View oftheData
Patients presenting with left-sided colonic diverticulitis complicated by abscesses
not amenable to percutaneous drainage present a clinical challenge. There are several treatment strategies described for this complex and heterogenous patient population. These include a trial of antibiotics alone, laparoscopic lavage, staged fecal
diversion followed by interval colectomy, and sigmoid resection (laparoscopic/open
Hartmann procedure or primary anastomosis with/without a protective diverting
ostomy). Unlike for patients who present with an indication for immediate operation such as peritonitis, the timing and choice of surgical intervention is not well
studied for stable patients with diverticular abscesses (Hinchey Ib/II). Patients with
small abscesses <3cm are generally successfully managed with antibiotics alone.
Those with larger abscesses not amenable to percutaneous drainage can also be
managed with antibiotics alone initially if they are clinically stable. Clinicians
should be aware of the relatively high failure rate and recurrence rate in this patient
population treated with antibiotics alone [2, 7, 8]. Repeat cross sectional imaging
should be considered in patients treated initially with antibiotics who remain clinically stable but fail to improve after a few days (inability to tolerate enteral feeds,
persistent localized pain). In such instances, percutaneous drainage may become
feasible if abscesses enlarge or a safe window becomes evident.
For patients who fail to improve after a trial of antibiotics alone, surgical intervention is required. Procedure of choice remains unclear and may depend on multiple
patient factors and surgical expertise available. There is more robust data on surgical
management of patients with Hinchey III diverticulitis that may be extrapolated to
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B. Giri and G. A. Rubio
those with Hinchey Ib/II [1]. In general, there has been a shift recently towards utilization of both minimally invasive techniques and of primary anastomosis with/without protective stoma. Primary anastomosis with/without protective stoma offers
several advantages including lower overall morbidity and signicantly higher long
term stoma free rates [9, 10]. In these settings, minimally invasive approaches have
been shown to be safe and offer additional advantages with lower overall morbidity
[11]. In the setting of stable Hinchey Ib/II patients that failed antibiotic therapy and
require surgery, laparoscopic sigmoid resection with primary anastomosis should be
strongly considered when feasible and expertise is available. Hartmann procedure
also remains a safe and effective operation for patients with left sided colonic diverticulitis, particularly in hemodynamically unstable patients or those otherwise high
risk for anastomotic failure such as those that are immunocompromised. Surgical
expertise plays an important role in decision to perform a Hartmann procedure versus primary anastomosis. Another option that has been studied in patients with
Hinchey II and Hinchey III diverticulitis is laparoscopic lavage. Enthusiasm for this
approach has recently waned with recent studies primarily including Hinchey III
patients showing higher rates of treatment failure, recurrence, and need for secondary procedures compared to sigmoid resection [12]. Similar results were reported in
one study that included a subset of patients with Hinchey II diverticulitis [4].
Therefore, there is insufcient evidence currently to widely recommend laparoscopic
lavage for patients with diverticular abscess not amenable to percutaneous drainage.
There may be a role for this less invasive approach in a subset of patients that needs
to be further elucidated with additional studies.
There is also insufcient data to support staged resections in patients with
Hinchey II diverticulitis consisting of initial diverting loop ileostomy followed by
interval sigmoid resection and subsequent ileostomy closure. Although these three
staged resections were commonly done in the past for more severe fulminant diverticulitis, perioperative mortality was found to be higher in these patients [13].
However, recently this approach has been reported to be safe and associated with
favorable long term outcomes including high rates of stoma closure [3]. There may
be a subset of patients that may benet from this approach, such as those with signicant perioperative risk factors during index hospitalization. Future studies are
needed to determine which patients, if any, would most benet from this approach.
In summary, there is limited, low quality, evidence evaluating optimal management of patients with diverticular abscess not amenable to percutaneous drainage.
Based on these data, we recommend sigmoid resection and primary anastomosis
with/without protective ileostomy or a Hartman procedure, depending on local
expertise and patient factors. The role of laparoscopic lavage or initial fecal diversion alone in these patients requires further study.
References
1. Hall J, Hardiman K, Lee S, Lightner A, Stocchi L, Paquette IM, etal. The American Society of
Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic
diverticulitis. Dis Colon Rectum. 2020 Jun;63(6):728–47.
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2. Gregersen R, Mortensen LQ, Burcharth J, Pommergaard HC, Rosenberg J. Treatment of
patients with acute colonic diverticulitis complicated by abscess formation: a systematic
review. Int J Surg. 2016 Nov;35:201–8.
3. Graham A, Umanskiy K, Hurst R, Shogan B, Hyman N, Olortegui K.Back to the FUTURE-is
diversion without resection a safe option for complicated diverticulitis? Dis Colon Rectum.
2022:73–4.
4. Tartaglia D, Di Saverio S, Stupalkowska W, Giannessi S, Robustelli V, Coccolini F,
et al. Laparoscopic peritoneal lavage versus laparoscopic sigmoidectomy in complicated
acute diverticulitis: a multicenter prospective observational study. Int J Color Dis. 2019
Dec;34(12):2111–20.
5. Buchwald P, Dixon L, Wakeman CJ, Eglinton TW, Frizelle FA.Hinchey I and II diverticular
abscesses: long-term outcome of conservative treatment. ANZ J Surg. 2017 Dec;87(12):1011–4.
6. Goleri R, Cappelli A.Computed tomography-guided percutaneous abscess drainage in coloproctology: review of the literature. Tech Coloproctol. 2007 Sep;11(3):197–208.
7. Rosen DR, Pott EG, Cologne KG, Lee SW, Ault GT, Grabo DJ, etal. Percutaneous drainage
for hinchey Ib and II acute diverticulitis with abscess improves outcomes. Turk J Gastroenterol.
2019 Nov;30(11):976–83.
8. Brandt D, Gervaz P, Durmishi Y, Platon A, Morel P, Poletti PA.Percutaneous CT Scan-guided
drainage vs. antibiotherapy alone for Hinchey II diverticulitis: a case-control study. Dis Colon
Rectum 2006 Oct;49(10):1533–1538.
9. Binda GA, Karas JR, Serventi A, Sokmen S, Amato A, Hydo L, etal. Primary anastomosis vs
nonrestorative resection for perforated diverticulitis with peritonitis: a prematurely terminated
randomized controlled trial. Color Dis. 2012 Nov;14(11):1403–10.
10. Oberkoer CE, Rickenbacher A, Raptis DA, Lehmann K, Villiger P, Buchli C, et al. A
multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure
for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 2012
Nov;256(5):819–826; discussion 826-827.
11. Katsuno G, Fukunaga M, Nagakari K, Yoshikawa S.Laparoscopic one-stage resection of right
and left colon complicated diverticulitis equivalent to Hinchey stage I-II.Surg Today. 2011
May;41(5):647–54.
12. Penna M, Markar SR, Mackenzie H, Hompes R, Cunningham C.Laparoscopic lavage versus
primary resection for acute perforated diverticulitis: review and meta-analysis. Ann Surg. 2018
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Hartmann Procedure vs Primary
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Anastomosis forAcute Complicated
36
Diverticulitis
SusannaS.Hill andAneelDamle
Introduction
The prevalence of acute diverticulitis has been increasing in Western nations. A
recent 2016 prospective study found 42% of patients on screening colonoscopy had
diverticulosis [1, 2] and progression to diverticulitis has been estimated at 10–25%
[3]. Historically, surgical management options for patients presenting with acute
complicated diverticulitis have included a 3-stage operative approach proposed by
Rankin and Brown (diverting colostomy with drainage, segmental colectomy,
colostomy reversal) [4], the 2-stage Hartmann’s procedure (segmental colectomy
with end colostomy, colostomy reversal) [5], segmental colectomy (with consideration for diverting loop ileostomy, on-table colonic lavage, and laparoscopic
lavage) [6].
The current practice has shifted to more frequently performing segmental colectomy with diverting loop ileostomy over the more traditional Hartmann’s procedure. The primary reasons for this culture shift include higher reversal rates and
less technically challenging ostomy reversal with primary anastomosis with proximal diversion. The most recent set of American Society of Colon and Rectal
Surgery guidelines for treatment of left-sided diverticulitis discuss emergency
surgery for acute diverticulitis. They recommend urgent sigmoid colectomy for
patients who have diffuse peritonitis and that restoration of bowel continuity
S. S. Hill
Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota
School of Medicine, Minneapolis, MN, USA
A. Damle (*)
Colon and Rectal Surgery Associates, University of Minnesota School of Medicine,
Minneapolis, MN, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_36
397
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